A frail, elderly client is admitted to the unit with a diagnosis of pneumonia. Which finding is
most important for the registered nurse (RN) to report to the healthcare provider?
A. Fever and chills
B. Confusion and dehydration
C. Crackles in the lung fields
D. Nausea and vomiting B. Confusion and dehydration
Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and perfusion
in this frail elderly client. (A), (C) and (D) are all common with pneumonia, but the most
important finding is confusion and evidence of dehydration, which require treatment for this frail
elderly client.
A frail elderly couple asks the registered nurse (RN) if they have to watch their salt intake
because food does not taste as good as it used to so they have to season most foods. What
information should the RN offer the couple?
A. Boredom may influence how the taste of food is perceived, and different seasonings can
stimulate taste.
B. With age, an increase in sodium intake is needed to compensate for a decrease in renal
function.
C. Short-term memory loss and confusion may be the reason they want to over-season their food.
D. Taste buds often are dull due to atrophy so older clients should use other seasonings instead of
salt. D. Taste buds are often dull due to atrophy so older clients should use other
seasonings instead of salt.
Rationale: Taste buds atrophy with normal aging, which influences an older client's sensitivity to
taste and is often compensated for the use of stronger tasting seasonings. (A), (B), and (C) are
not normal aging processes related to taste.
After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly client with
chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The client has a long
history of smoking and still smokes a pack of cigarettes a day. Which finding should the
registered nurse (RN) report to the healthcare provider?
A. Barrel chest with increased chest diameter
B. Crackles and pulse oximetry level of 88%
C. Low hemoglobin and hematocrit levels
D. Arterial blood gases indicating respiratory acidosis B. Crackles and pulse oximetry
level of 88%
Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact adequate
oxygenation, which should be reported to the HCP. (A) occurs due to chronic hyperinflation of
the lungs and is common in clients with COPD. Anemia (C) is frequently identified in clients
with COPD, and respiratory acidosis (D) due to CO2 retention contributes to a lower blood pH.
An older female client recently moved to an assisted living facility. The family explains to the
registered nurse (RN) that the client is unmanageable and always confused, disoriented and
depressed. The client asks the RN repeatedly, "Where am I?". How should the RN respond?
A. Explain that she is in a new home called an assisted living community
,B. Question the client about her perception of where she might be now.
C. Distract the client with a scenario that she is on an outing with her family.
D. Reassure the client not to worry because she will meet new friends. A. Explain that she is
in a new home called an assisted living community.
Rationale: Reality re-orientation (A) is the best response for a client who is confused because the
response is consistent and true. (B, C, and D) do not provide the client with feedback that is
reality based.
A new resident in an assisted living facility is an older client who is experiencing short-term
memory loss and confusion. Which activity should the registered nurse (RN) schedule the client
to do during the day?
A. Arts and crafts
B. Current events discussion group
C. Group sing-along
D. Daily exercise group D. Daily exercise group
Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes the
client's stress to remember. (A), (C), and a current events discussion group (B) are thought-
provoking activities that require attention to detail and short-term memory to participate in the
group activity which may be stressful and frustrating to the resident who has difficulty
remembering sequence of the details.
The hospice nurse is completing a focused assessment of an older female client with end stage
Alzheimer's disease, who recently fractured her hip. What technique should the registered nurse
(RN) use to determine the client's pain?
A. Use the FACE pain scale
B. Ask the client to rate pain on a scale of 1 to 10
C. Observe for facial grimacing
D. Review documentation of recent eating habits C. Observe for facial grimacing
Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a client
who cannot communicate due to Alzheimer disease. (A) and (B) may not be understood by a
client with end-stage Alzheimer's disease. (D) is not a helpful tool for pain assessment.
An older male client arrives at the clinic for an annual physical examination. While the nurse
assesses the client, the client states that he is having intimacy problems with his wife. Which
information should the nurse provide to elicit more information from the client?
A. Query client to clarify the client's idea of an intimacy problem.
B. Discuss benign prostatic hypertrophy (BPH) and ejaculation.
C. Explore the frequency that he experiences erectile dysfunction (ED)
D. Determine if the client's wife is young enough to get pregnant A. Query client to clarify the
client's idea of an intimacy problem.
Rationale: Clarification of the client's concern is needed to appropriately address the specific
concern about intimacy issues (A). (B), (C), and (D) are details that the client should present, not
the RN.
,The registered nurse (RN) is caring for an older female client with a 20 year history of
rheumatoid arthritis (RA), who is admitted for carpel tunnel release. Which finding associated
with RA should the RN document?
A. Asymmetrical joint deformity
B. Small joint involvement in fingers
C. Crepitation or grating sensation in joints
D. Weight bearing joint involvement B. Small joint involvement in fingers.
Rationale: Small joint involvement (B) is common in rheumatoid arthritis. (A), (C) and (D) are
findings that different OA from RA.
The registered nurse (RN) is re-enforcing discharge instructions with the family of an older client
who was recently admitted for an intestinal obstruction. Which statement indicates that the
family understands the instructions?
A. Increase protein and carbohydrates in the daily diet
B. Limit activity to bed rest for the first week and increase mobility incrementally each week
C. Report abdominal distention, constipation or any other nausea and vomiting to the healthcare
provider
D. Drink liquids 2 hours after meals instead of during meals C. Report abdominal
distention, constipation, or any nausea and vomiting to the healthcare provider.
Rationale: (C) are symptoms that occur with intestinal obstruction and should be addressed
immediately. (A, B, and D) are not indicated for a client who has been discharged for intestinal
obstruction.
An older client is transferred to a telemetry unit after placement of a pacemaker. What action
should the registered nurse (RN) take first?
A. View incision site
B. Obtain a blood pressure
C. Establish telemetry monitoring
D. Evaluate client for pain C. Establish telemetry monitoring.
Rationale: The first action is to establish continuous telemetry monitoring (C) to ensure the
pacemaker is functioning properly. (A, B and D) should be implemented after the client's heart
rate and rhythm are successfully being monitored.
Older clients are at highest risk for abuse and neglect due to which factors? (Select all that
apply.)
A. Needs are greater than the caretaker's abilities
B. Client's declining strength
C. Fixed income
D. Longer life expectancy
E. Lack of exposure to technology and trends A. Needs regretter than the caretaker's
abilities
B. Client's declining strength
Rationale: When needs are not being met due to lack of ability of the caretaker (A), stress and
feelings of failure may be expressed through neglect and abuse. Decline in strength (B) increases
, the older client's vulnerability to resist or respond to elder abuse. (C, D, E) do not increase the
risk for neglect and abuse.
An older female client who has been taking hydrocodone/acetaminophen (Lortab) q4 hours for
chronic back pain for the past 5 years tells the registered nurse (RN) that she cannot live without
her pain pills. When asked if she is addicted, the client states that she is not an addict because the
healthcare provider prescribed the pain pills. Which coping mechanism should the RN determine
the client is using about her addiction?
A. Lack of knowledge about narcotic medications
B. Rationalization to support narcotic use
C. Transfer of blame to healthcare provider
D. Justification of narcotic use due to chronic pain B. Rationalization to support narcotic use.
Rationale: The client is using rationalization to maintain self-esteem when she is questioned by
stating that she is not addicted because she is taking medication prescribed by a healthcare
provider. (A) may be possible, but the client is being specifically asked about possible addiction.
(C) and (D) underlie the complexity of denial in addiction, but the client is trying to maintain
self-esteem through rationalization.
A family member brings their aging father to the clinic because he has been alert and oriented
during the day but agitated and disoriented in the evening. The registered nurse (RN) reviews the
client's list of current medications with the client and family. Which action taken by the RN is
most important?
A. Medication review with family caregivers is the RN's responsibility
B. Multiple medications can contribute to sundowner-like symptoms
C. Medication recall is the best way to evaluate the client's memory
D. Reviewing medication actions is a component of effective client care B. Multiple
medications can contribute to sundowner like symptoms.
Rationale: Older clients may see a variety of HCP which can increase the chance of
polypharmacy that compounds the workload of metabolic pathways that may be less efficient
due to the aging process. Multiple medication interactions may contribute to sundowner like
symptoms; reviewing medication actions and interactions provides the information that may
indicate polypharmacy leading to sundowner syndromes.
Since his arrival in an assisted living community, an older male client is having difficulty going
to sleep. Which intervention should the registered nurse (RN) implement first?
A. Encourage client to take a warm bath at night
B. Ask the client what has helped him in the past
C. Recommend that the client not take daytime naps
D. Offer the client a glass of warm milk before bedtime B. Ask the client what has helped
him in the past.
A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which
observation by the nurse warrants immediate intervention?
Apical heart rate of 60.
Sweating across the forehead.
Doesn't suck well.
Respiratory rate of 30 breaths per minute. Apical heart rate of 60.
most important for the registered nurse (RN) to report to the healthcare provider?
A. Fever and chills
B. Confusion and dehydration
C. Crackles in the lung fields
D. Nausea and vomiting B. Confusion and dehydration
Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and perfusion
in this frail elderly client. (A), (C) and (D) are all common with pneumonia, but the most
important finding is confusion and evidence of dehydration, which require treatment for this frail
elderly client.
A frail elderly couple asks the registered nurse (RN) if they have to watch their salt intake
because food does not taste as good as it used to so they have to season most foods. What
information should the RN offer the couple?
A. Boredom may influence how the taste of food is perceived, and different seasonings can
stimulate taste.
B. With age, an increase in sodium intake is needed to compensate for a decrease in renal
function.
C. Short-term memory loss and confusion may be the reason they want to over-season their food.
D. Taste buds often are dull due to atrophy so older clients should use other seasonings instead of
salt. D. Taste buds are often dull due to atrophy so older clients should use other
seasonings instead of salt.
Rationale: Taste buds atrophy with normal aging, which influences an older client's sensitivity to
taste and is often compensated for the use of stronger tasting seasonings. (A), (B), and (C) are
not normal aging processes related to taste.
After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly client with
chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The client has a long
history of smoking and still smokes a pack of cigarettes a day. Which finding should the
registered nurse (RN) report to the healthcare provider?
A. Barrel chest with increased chest diameter
B. Crackles and pulse oximetry level of 88%
C. Low hemoglobin and hematocrit levels
D. Arterial blood gases indicating respiratory acidosis B. Crackles and pulse oximetry
level of 88%
Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact adequate
oxygenation, which should be reported to the HCP. (A) occurs due to chronic hyperinflation of
the lungs and is common in clients with COPD. Anemia (C) is frequently identified in clients
with COPD, and respiratory acidosis (D) due to CO2 retention contributes to a lower blood pH.
An older female client recently moved to an assisted living facility. The family explains to the
registered nurse (RN) that the client is unmanageable and always confused, disoriented and
depressed. The client asks the RN repeatedly, "Where am I?". How should the RN respond?
A. Explain that she is in a new home called an assisted living community
,B. Question the client about her perception of where she might be now.
C. Distract the client with a scenario that she is on an outing with her family.
D. Reassure the client not to worry because she will meet new friends. A. Explain that she is
in a new home called an assisted living community.
Rationale: Reality re-orientation (A) is the best response for a client who is confused because the
response is consistent and true. (B, C, and D) do not provide the client with feedback that is
reality based.
A new resident in an assisted living facility is an older client who is experiencing short-term
memory loss and confusion. Which activity should the registered nurse (RN) schedule the client
to do during the day?
A. Arts and crafts
B. Current events discussion group
C. Group sing-along
D. Daily exercise group D. Daily exercise group
Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes the
client's stress to remember. (A), (C), and a current events discussion group (B) are thought-
provoking activities that require attention to detail and short-term memory to participate in the
group activity which may be stressful and frustrating to the resident who has difficulty
remembering sequence of the details.
The hospice nurse is completing a focused assessment of an older female client with end stage
Alzheimer's disease, who recently fractured her hip. What technique should the registered nurse
(RN) use to determine the client's pain?
A. Use the FACE pain scale
B. Ask the client to rate pain on a scale of 1 to 10
C. Observe for facial grimacing
D. Review documentation of recent eating habits C. Observe for facial grimacing
Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a client
who cannot communicate due to Alzheimer disease. (A) and (B) may not be understood by a
client with end-stage Alzheimer's disease. (D) is not a helpful tool for pain assessment.
An older male client arrives at the clinic for an annual physical examination. While the nurse
assesses the client, the client states that he is having intimacy problems with his wife. Which
information should the nurse provide to elicit more information from the client?
A. Query client to clarify the client's idea of an intimacy problem.
B. Discuss benign prostatic hypertrophy (BPH) and ejaculation.
C. Explore the frequency that he experiences erectile dysfunction (ED)
D. Determine if the client's wife is young enough to get pregnant A. Query client to clarify the
client's idea of an intimacy problem.
Rationale: Clarification of the client's concern is needed to appropriately address the specific
concern about intimacy issues (A). (B), (C), and (D) are details that the client should present, not
the RN.
,The registered nurse (RN) is caring for an older female client with a 20 year history of
rheumatoid arthritis (RA), who is admitted for carpel tunnel release. Which finding associated
with RA should the RN document?
A. Asymmetrical joint deformity
B. Small joint involvement in fingers
C. Crepitation or grating sensation in joints
D. Weight bearing joint involvement B. Small joint involvement in fingers.
Rationale: Small joint involvement (B) is common in rheumatoid arthritis. (A), (C) and (D) are
findings that different OA from RA.
The registered nurse (RN) is re-enforcing discharge instructions with the family of an older client
who was recently admitted for an intestinal obstruction. Which statement indicates that the
family understands the instructions?
A. Increase protein and carbohydrates in the daily diet
B. Limit activity to bed rest for the first week and increase mobility incrementally each week
C. Report abdominal distention, constipation or any other nausea and vomiting to the healthcare
provider
D. Drink liquids 2 hours after meals instead of during meals C. Report abdominal
distention, constipation, or any nausea and vomiting to the healthcare provider.
Rationale: (C) are symptoms that occur with intestinal obstruction and should be addressed
immediately. (A, B, and D) are not indicated for a client who has been discharged for intestinal
obstruction.
An older client is transferred to a telemetry unit after placement of a pacemaker. What action
should the registered nurse (RN) take first?
A. View incision site
B. Obtain a blood pressure
C. Establish telemetry monitoring
D. Evaluate client for pain C. Establish telemetry monitoring.
Rationale: The first action is to establish continuous telemetry monitoring (C) to ensure the
pacemaker is functioning properly. (A, B and D) should be implemented after the client's heart
rate and rhythm are successfully being monitored.
Older clients are at highest risk for abuse and neglect due to which factors? (Select all that
apply.)
A. Needs are greater than the caretaker's abilities
B. Client's declining strength
C. Fixed income
D. Longer life expectancy
E. Lack of exposure to technology and trends A. Needs regretter than the caretaker's
abilities
B. Client's declining strength
Rationale: When needs are not being met due to lack of ability of the caretaker (A), stress and
feelings of failure may be expressed through neglect and abuse. Decline in strength (B) increases
, the older client's vulnerability to resist or respond to elder abuse. (C, D, E) do not increase the
risk for neglect and abuse.
An older female client who has been taking hydrocodone/acetaminophen (Lortab) q4 hours for
chronic back pain for the past 5 years tells the registered nurse (RN) that she cannot live without
her pain pills. When asked if she is addicted, the client states that she is not an addict because the
healthcare provider prescribed the pain pills. Which coping mechanism should the RN determine
the client is using about her addiction?
A. Lack of knowledge about narcotic medications
B. Rationalization to support narcotic use
C. Transfer of blame to healthcare provider
D. Justification of narcotic use due to chronic pain B. Rationalization to support narcotic use.
Rationale: The client is using rationalization to maintain self-esteem when she is questioned by
stating that she is not addicted because she is taking medication prescribed by a healthcare
provider. (A) may be possible, but the client is being specifically asked about possible addiction.
(C) and (D) underlie the complexity of denial in addiction, but the client is trying to maintain
self-esteem through rationalization.
A family member brings their aging father to the clinic because he has been alert and oriented
during the day but agitated and disoriented in the evening. The registered nurse (RN) reviews the
client's list of current medications with the client and family. Which action taken by the RN is
most important?
A. Medication review with family caregivers is the RN's responsibility
B. Multiple medications can contribute to sundowner-like symptoms
C. Medication recall is the best way to evaluate the client's memory
D. Reviewing medication actions is a component of effective client care B. Multiple
medications can contribute to sundowner like symptoms.
Rationale: Older clients may see a variety of HCP which can increase the chance of
polypharmacy that compounds the workload of metabolic pathways that may be less efficient
due to the aging process. Multiple medication interactions may contribute to sundowner like
symptoms; reviewing medication actions and interactions provides the information that may
indicate polypharmacy leading to sundowner syndromes.
Since his arrival in an assisted living community, an older male client is having difficulty going
to sleep. Which intervention should the registered nurse (RN) implement first?
A. Encourage client to take a warm bath at night
B. Ask the client what has helped him in the past
C. Recommend that the client not take daytime naps
D. Offer the client a glass of warm milk before bedtime B. Ask the client what has helped
him in the past.
A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which
observation by the nurse warrants immediate intervention?
Apical heart rate of 60.
Sweating across the forehead.
Doesn't suck well.
Respiratory rate of 30 breaths per minute. Apical heart rate of 60.
